1. Discuss reasons why patients might need central venous access.

Central Line Vascular Devices (CVADs) now provide medication, fluid, and nutrition to patients ranging from the critically ill to those who are active and ambulatory.

2. Discuss the various types of central venous catheters: PICC Lines, Non-tunneled catheters, Tunneled catheters and Implanted ports.
PICC Lines are peripherally inserted central catheters. Inserted in a peripheral vein and threaded into the superior vena cava, PICC catheters can be used for all therapies and blood collection. They're best suited for patients requiring daily infusion therapies for up to 6 months. No recommended maximum dwell time has been established; some patients have used a PICC for a year or more without problems. Insertion: PICC lines can be inserted by a specially prepared nurse or a physician in various settings, including the radiology suite, a physician's office, or the patients home. Before starting, the clinician measures the patient to make sure the catheter is the right length to reach its destination. He then inserts the catheter into a vein in the antecubital fossa, such as the basilic or cephalic vein, and advances it into the superior vena cava. (In some cases, a PICC is advanced only into the peripheral vasculature. These are considered peripheral or midline catheters, not CVADs.) Because PICCs are longer than other CVADs (20 to 25 inches [50 to 62.5 cm], as opposed to 6 to 8 inches), you may find infusing or drawing blood from small-gauge PICC lines (such as #2 or #3 French catheters) difficult. These catheters also tend to infuse fluids more slowly and occlude faster than other CVADs. However, the incidence of catheter-related infection is only around 1%. Nursing care. After PICC insertion, apply a transparent dressing to the insertion site so you can observe it without disturbing the dressing; confirm proper placement with an X-ray. Change the dressing in 24 hours, then every 7 days (sooner if its soiled or loose), according to your facility's protocol. Measure and document the external length of the catheter with each dressing change. If you note any change in the external length, obtain an X-ray to check catheter position. When applying a dressing, place the securing device on the catheter hub. Remember that the PICC dressings purpose is to anchor the catheter in place and act as a bacterial seal. Most PICCs are openended and vulnerable to catheter occlusion. Flush open-ended PICCs with heparin, 100 units/ml (total volume, 3 ml). Flush the catheter after each use with the SASH protocol; flush it daily if its idle. Follow the manufacturer's recommendations for maintaining closedended PICCs. You can collect blood specimens from a PICC catheter using a 10-ml syringe, but don't use vacuum blood-collection systems, which generate extremely high pressure and can rupture PICC catheters.

You may be responsible for removing a PICC catheter if you've been properly prepared to do so and your institutions policy permits nurses to remove PICCs. Before beginning, verify the total catheter length. Using clean gloves, remove

the dressing and gently pull the catheter out of the vein. Immediately apply pressure to the site with a gauze pad. Occasionally, a PICC catheter is difficult to remove. If you meet resistance, don't tug on it or it may break. Following Infusion Nurses Society (INS) Standards of Practice, stop the procedure, coil the external portion of catheter, apply a dressing, and notify the primary care provider. After the catheter has been completely removed, apply an occlusive dressing over the exit site to protect it from infection and prevent air embolism. Many nurses incorrectly believe that transparent dressings are occlusive. But these semipermeable membranes permit air to circulate through the dressing to prevent perspiration from collecting under the dressing. To make a transparent dressing occlusive, apply povidone-iodine ointment or antibacterial ointment to the exit site. The jellylike consistency of ointment occludes the wound. When documenting CVAD removal, note the type of dressing applied and the catheter length, as you would for all CVADs. Inspect the catheter exit site every 24 hours and change the dressing every 24 hours until a scab has formed, then discontinue the occlusive dressing.

Tunneled catheters-- Designed for long-term use, tunneled catheters can remain in place for many years. Examples include the Hickman, Broviac, Groshong, Hohn, and Leonard catheter. Chronically ill patients who need long-term IN therapy are candidates for these catheters, which are made of durable, medical-grade silicone to help avoid breakage. They're also ideal for active patients: Once the catheter tunnel and cuff matures, these patients can move about without restriction, even swimming normally. Insertion: Tunneled catheters, which are inserted by physicians in the operating room (OR) or interventional radiology suite, are placed through a surgical subcutaneous tunnel on the chest. During insertion, the physician uses a needle to locate the subclavian vein and advances the catheter tip into the superior vena cava. With a blunt-ended trocar, he creates the subcutaneous tunnel from the subclavian vein down the chest wall. Catheter manufacturers recommend that the catheter exits from the tunnel at nipple level. All tunneled catheters have a small synthetic cuff that sits within the subcutaneous tunnel. Within 7 to 10 days of catheter insertion, scar tissue grows onto the cuff, anchoring the catheter and preventing microorganisms from migrating up the tunnel. Once the cuff heals into place, the sutures can be removed and no dressing is required unless the patient is immunocompromised and at high risk for catheter infection.

Nontunneled CVADs: Fast access Nontunneled CVADs are large-- bore catheters inserted into the subclavian vein. From 6 to 8 inches (15 to 20 cm) long, they can have from one to four lumens and are made of either soft silicone or a stronger polyurethane. Some types are impregnated with heparin, chlorhexidine, or an antibiotic. Because they can

be inserted quickly and can handle any kind of I.V. therapy as well as blood collection, nontunneled CVADs are especially useful in an emergency Insertion: Nontunneled CVADs are usually inserted by a physician (although a specially prepared nurse practitioner or physician assistant may do so in some circumstances). Observing strict aseptic technique, the physician first inserts a 14-gauge needle into the subclavian vein, using the clavicle as a guide. When she sees venous blood return in the syringe, she'll disengage the syringe from the needle, feed a wire through the needle into the subclavian vein, and remove and discard the needle. She'll then feed the catheter over the wire into the subclavian vein and brachiocephalic vein. When the tip rests in the superior vena cava, she'll remove the wire. No standard has been set for how long these catheters can remain in place. Nursing care: After insertion, the insertion site is covered with a dressing to prevent microorganisms from entering the venous system through the insertion site. Of the four types of CVADs, nontunneled catheters have the highest infection rate, so meticulous nursing care is crucial. (See Changing CURD Dressings.) Obtain blood return from a nontunneled catheter and any other CVAD before each use. In addition, flush the catheter routinely to remove any drug residue from the lumen and prevent the catheter from clotting if blood refluxes into the lumen. Use the SASH method: Saline, Administer the drug (or withdraw blood), Saline, Heparin. If the catheter isn't in use, flush it once a day with heparin. Most CVADs have a volume of 1 to 3 ml. Flush with a volume that's at least twice the volume of the catheter and extension tubing. Use only 10-ml or larger syringes. Remember, the larger the syringe barrel, the lower the pressure. Using a small-barrel, high-pressure syringe would increase the chance of breaking the catheter.

Implanted ports: Out of sight ---Totally implanted under the skin, this type of CVAD has no external parts. Considered a long-term CVAD, an implanted port may last for 2,000 punctures. They're best used for cyclic therapies, such as chemotherapy or antibiotics, and for treatments for chronic or longterm illnesses, such as cancer or cystic fibrosis. They can handle both bolus injections and continuous infusions. Ports are composed of a metal or plastic housing that surrounds a self-sealing silicone gel. A silicone catheter is attached to the port housing. Besides minimizing infection risks, an implanted port may be more convenient and cosmetically appealing to active young adults than other CVADs. However, they also have drawbacks: They must be surgically implanted and accessing them may be painful for the patient.

Insertion: Ports are usually inserted in the OR or interventional radiology suite. The surgeon makes a subcutaneous pocket for the port housing, inserts the catheter into the subclavian vein, and advances it into the superior vena cava. (Depending on the therapy, the catheter can be inserted into any vein or artery, the brain, or the epidural space for pain control.) The insertion site requires a dressing until it heals. Nursing care: To access the port, you'll

push a special noncoring Huber needle through the skin. A traditional needle would core the septum, resulting in blood leakage and contact with air. A damaged port must be surgically removed immediately. To access the port, first palpate the area to locate it. Numb the area with a topical anesthetic cream, ice, or ethyl chloride spray, depending on the prescriber's order and facility protocol. Using sterile technique, clean the area with alcohol followed by povidone-iodine. With the thumb and index finger of your nondominant hand, feel for the edge of the port housing and stabilize the port between your fingers. Push the Huber noncoring needle through the skin and silicone gel until you hit the port's rigid back. Confirm that the needle is correctly placed by checking for blood return, then flush with saline. After accessing the port, cover the Huber needle with a transparent dressing and start the infusion as ordered. Change the Huber needle and dressing every 7 days. If an accessed port isn't being used to infuse fluid, flush it daily with 5 ml of heparin (100 units/ml). If the port isn't accessed or in routine use, access and flush it every 28 days to maintain patency. To draw blood, use a 10-ml syringe or a vacuum blood-- collection system. Discard the initial 5 to 10 ml to remove any medication that may alter lab results.

3. During insertion of a central line, it is important for the nurse to monitor the client. Give signs and symptoms of the following complications and treatment that should be provided. Pneumothorax, Air Embolism and Arterial Puncture

4. Due to the ability to provide a large amount of fluid and since a client with central access is usually ill, circulatory overload can occur. Give signs and symptoms of circulatory overload, how to treat it and how to prevent it.

5. Infection is a very serious complication of central venous catheters. Give signs and symptoms of infection, possible causes and treatment.

6. You have an order to perform a blood draw from a central venous catheter. Briefly describe this procedure.

1. Which of the following is CORRECT about PICC insertion?

PICC lines can only be inserted by a qualified physician The PICC's tip should rest in the right atrium PICC lines are only used for dialysis treatments PICC's are ideally inserted into the basilic vein

During removal of the central venous catheter, it is important to decrease the risk of accidental air embolism. The nurse can accomplish this by having the client count to ten during the removal asking the client to preform the Valsalva maneuver or hold breath during removal having the client breathe out quickly during the removal

1. It is important to keep unused lines of a central venous catheter clamped because

having the client deep breathe and cough prior to removal

the clamp prevents entrance of air into the catheter the clamp equalizes pressure on the vein wall the clamp decreases pressure exerted when the client coughs or sneezes the clamp prevent the backflow of blood and clot formation

Central line dressing changes are done

using sterile technique including a mask using clean technique and having the client turn his head away from the site under surgically sterile conditions by the physician only